Want change? Lighten up.

As physicians, we frequently want our patients to change. We tell them to exercise more, eat differently, take their medications regularly, stop smoking. We explain why they should change, draw pictures, tell stories, cite literature. Our patients agree they will change – and then, nothing happens. So, how can we motivate them to make the changes that we know will be better for their health?

While we are clear that these changes are good, the fact is that our patients remain ambivalent. They know that smoking or excessive drinking is bad for their health. But they also know that when they are anxious, smoking calms their nerves. And when everyone goes out for a drink, they like to be a part of the group. It’s an important source of friendship for them. Most of us have felt this ambivalence. We are sure that we want to eat less and lose some weight, but when handed a piece of delicious chocolate cake, we are somehow unable to turn it down.

One effective way of helping our patients move through their ambivalence is found in the field of Motivational Interviewing. Skilled practitioners have usually spent years studying and perfecting their approach. But we can employ a simple version of this highly useful technique whenever we sense ambivalence.

The first step is to really listen to what our patient is ambivalent about and to name the two sides. “It sounds like you would really like to stop smoking, but you also feel as if smoking plays a big part in your social life and in helping you relax.” Dr. Igor Koutzenok at UC-San Diego suggests that we follow with these questions:
Why would you like to stop smoking?
How might you go about stopping?
What are the 3 best reasons for stopping?
On a scale of 1 to 10, how important is it for you to stop smoking?
Why are you at (the number they gave) instead of at number (two numbers below that)?
Then end with: What do you think you will do next?

Throughout this questioning, the best thing we can do is to listen. People change best when they hear themselves state the reasons and a plan for change. In Motivational Interviewing, this is called “change talk.” When a person is ambivalent, if we speak in favor of change, he will counter with an argument against it in order to maintain the ambivalence. But if we allow him to speak in favor of change, he will more likely move in that direction. As Miller and Rollnick suggest in their book, Motivational Interviewing, we can enhance the effect of change talk by simply making a positive comment such as, “that sounds like a good idea.”

With more time, we can explore our patient’s readiness to change as well as her confidence that she can do it. Tying the change into an important value is also helpful. Mentioning that our family-oriented patient wants to be alive and active in the lives of children or grandchildren can be very motivating in making changes such as smoking cessation.

Change is difficult and usually doesn’t happen instantly. By allowing our patient to explore her ambivalence and verbalize her own reasons and plan for change, we can often be more effective in a shorter amount of time than the countless lectures we have all delivered trying to talk our patients into healthy behaviors.

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About Helane Fronek

Over the past 28 years I have had a fascinating and fulfilling career in medicine, initially practicing as a general internist and then as a procedural specialist, caring for patients with vein disorders. As Assistant Clinical Professor of Medicine at UC- San Diego School of Medicine, I’m thrilled to be teaching medical students crucial communication skills along with many other aspects involved in the practice of medicine.
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